osteotomy around hip at one place with good image

1. Osteotomies Around Hip Joint
 Dr.Ankit
 Dr.B.L.Chandrakar

2. DEFINITION
 An osteotomy is a surgical corrective
procedure used to obtain a correct
biomechanical alignment of the extremity so as
to achieve equivocal load transmission,
performed with or without removal of a
portion of the bone.

3. OSTEOTOMY AROUND HIP -
CLASSIFICATION
 According to Anatomic Location
Femoral Osteotomy
 High Cervical.
 Intertrochanteric Osteotomy.
 Subtrochanteric Osteotomy.
 Greater Trochanteric
Pelvic Osteotomy
 Salvage Osteotomies : eg. Chiari, Shelf,
 Reconstructive Osteotomies : eg. Periacetabular, Single,
Double, Triple Innominate
Combined Osteotomy

4. INDICATIONS
 To Correct deformities
 coxa vara
 slipped upper femoral epiphysis
 Intracapsular cuneiform osteotomy by Dunn.
 Compensatory Basilar Osteotomy of Femoral
Neck.
 Extracapsular Base-of-Neck osteotomy.
 Ball-and-Socket Trochanteric Osteotomy.
 Pauwel’s osteotomy (Y).

5.  To obtain stability
 old unreduced dislocations.
 Lorenz bifurcation osteotomy.
 Schanz low subtrochanteric.
 Relief of pain
 osteoarathritis.
 Pauwel’s type I varus osteotomy.
 Pauwel’s type II valgus osteotomy.

6.  To obtain union
 Un-united fractures of femoral neck.
 McMurry’s osteotomy.
 Dickson's high geometric osteotomy.
 Schanz Angulation Osteotomy.
 unstable intertrochanteric fractures.
 Dimon Hughston Osteotomy.
 Sarmiento’s Osteotomy

7.  In Osteonecrosis of femoral head
 Sugioka’s transtrochanteric osteotomy.
 Varus deroation osteotomy of Axer.
- In paralytic disorders of hip.
 Varus Osteotomy.
 Rotational Osteotomy

8.  In congenital dislocation of hip
 Salters innominate osteotomy
 Pembertons innominate ostetomy
 Steels triple innominate osteotomy
 Shelf operation
 Chiari’s osteotomy

9. OVERVIEW OF PELVIC OSTEOTOMY

19. SALTER OSTEOTOMY
 INDICATIONS-Congruous hip reduction,<10-15 degrees
correction of acetabular index required ,paralytic
disorder,subluxation after septic arthritis
 PREREQUISITES- femoral head must be positioned opposite
the level of acetabulum,contracture of iliopsoas and adductor
muscles must be released, range of motion of the hip must be
good specially in abduction ,int rotation flexion
 AGE-18 months-6years
 AFTERCARE-hip spica for 8 to 12 wks,then partial weight
bearing on crutches ,followed by full weight bearing.result
assessed by center edge angle.

20. xrays
Salter osteotomy for congenital dislocation of hip. A, Residual
acetabular dysplasia and subluxation of right hip in 4-year-old
girl in whom open reduction had been performed at 9 months
of age. B, One year after repeat open reduction and Salter
innominate osteotomy.

21. PEMBERTON OSTEOTOMY
 PROCEDURE- Pemberton described a pericapsular
osteotomy of the ilium in which the osteotomy is
made through the full thickness of the bone from just
superior to the anteroinferior iliac spine anteriorly to
the triradiate cartilage posteriorly : the triradiate
cartilage acts as a hinge on which the acetabular roof
is rotated anteriorly and laterally.

22. Pemberton pericapsular osteotomy. A, Line of osteotomy beginning slightly
superior to anterior inferior iliac spine and curving into triradiate cartilage.
B, Completed osteotomy with acetabular roof in corrected position and
wedge of bone impacted into open osteotomy site.

23. PEMBERTON OSTEOTOMY

24.  INDICATION- >10-15 degrees correction of
acetabular index required ,small femoral head ,large
acetabulum.
 ADV- internal fixation not required .greater degree of
rotation can be achieved with less rotation of
acetabulum
 DISADV- Technically more difficult . Alters the
configuration and capacity of acetabulum and produces
joint incongruity that requires remodelling
 AGE-18months- 10 yr
 AFTERCARE-spica cast for 8 to 12 weeks
PEMBERTON PERICAPSULAR OSTEOTOMY

25. PERIACETABULAR OSTEOTOMY OF ILIUM
(PEMBERTON)
Pemberton acetabuloplasty. A, Symptomatic residual acetabular
dysplasia in 8-year-old girl after treatment of congenital dislocation of
right hip. B, After Pemberton acetabuloplasty

26. TRIPLE INNOMINATE OSTEOTOMY
(STEEL)

27. STEEL OSTEOTOMY
 The ischium, the superior pubic ramus and ilium superior to
the acetabulum are all divided and acetabulum is repositioned
and stabilized by bone graft and metal pins
 Objective- To establish a stable hip in anatomical position for
dislocation or subluxation of the hip in older children when
this is impossible by any one of the other osteotomies
 For the operation to be successful, the articular surfaces of the
joint must be congruous or become so when the acetabulum
has been redirected so that a functional, painless range of
motion is achieved and a Trendelenburg gait is absent

28. STEEL OSTEOTOMY
 INDICATIONS-Adolescents and skeletally mature adults with
residual dysplasia and subluxation in whom remodelling of
acetabulum is no longer anticipated
 ADVANTAGES-Better coverage of femoral head by articular
cartilage. Better hip joint stability,no need of spica cast.
 DISADVANTAGES- Technically difficult, does not change
size of acetabulum, distorts the hip such that natural child birth
may be impossible in adulthood

29. STEEL OSTEOTOMY
A, Osteotomies to be performed in iliac wing and superior and
inferior pubic rami. Note wedge of bone to be taken as graft from
superiormost portion of ilium.
B, Lateral view showing graft in place and fixation with two
Kirschner wires.

30. STEEL OSTEOTOMY
Steel triple innominate osteotomy.
A, Sixteen-year-old girl with painful
right hip, subluxation, and
acetabular dysplasia. B, After Steel
osteotomy. C, One year after
surgery
A
B
C

31. GANZ OSTEOTOMY: (BERNESE)
PRIACETUBULAR OSTEOTOMY.
 This Triplaner osteotomy is for adolescent and adult
dysplastic hip that required correction of congruency
& containment of the femoral head with little or no
arthritis.
 If significant degenerative changes are present a
proximal femoral osteotomy can be added.
 Approach- Smith Peterson approach.

32. GANZ OSTEOTOMY

33. GANZ OSTEOTOMY

34.  Advantages :
 Only one approach is used.
 A large amount of correction can be obtained in all
directions, including the medial and lateral planes.
 Blood supply to the acetabulum is preserved.
 The posterior column of the hemipelvis remains
mechanically intact, allowing immediate crutch walking
with minimal internal fixation.
 The shape of the true pelvis is unaltered, permitting a
normal child delivery.
 Can be combined with trochanteric osteotomy if needed.
Contd.

35. THE SHELF PROCEDURE (STAHELI)

36. SHELF OPERATION (STAHELI)
 Have commonly been performed to enlarge the volume of the
acetabulum.
 The objective is to create a shelf, the size of which is decided by
measuring the “width of augmentation” from the CE angle. The
shelf is put just above the acetabular margin. It secures two
layers of cancellous grafts bringing the reflected head of rectus
femoris forward over the graft and suturing it in its original
position.
 Best to do after 5 years of age.
 Indication : A deficient acetabulum that cannot be corrected by
redirectional, osteotomy is the primary indication.
 Contraindication :
 Dysplastic hip with spherical congruity suitable for
redirectional osteotomy
 Hip requiring open reduction.

37.  The placement of the acetabular slot is the
most critical part of the procedure; the slot
must be created exactly at the acetabular
margin
 Approach- Iliofemoral approach using bikini
incision parallel and 1cm below the Iliac crest

38. CENTER EDGE
ANGLE/ACETABULAR INDEX
 CE ANGLE-measured after 5 yr age, >25 normal,
<20 severe dysplasia
 AC IND- <27.5 normal, >30 dysplasia

39. CHIARI OSTEOTOMY
 PROCEDURE-It is performed at the superior margin of
the acetabulum and the pelvis inferior to the osteotomy
along with the femur is displaced medially.
This is also called as capsular interposition Arthroplasty
as the capsule is interposed between the shelf and the
femoral head.
 INDICATIONS-incongruous joint, dysplastic hip with
osteoarthritis ,other osteotomy not possible
 DISADVANTAGE-salvage osteotomy only, leaves
anterior acetabulum uncovered,abductor lurch common .

40. A, Line of osteotomy extending from immediately superior to
lip of acetabulum into sciatic notch. Osteotomy can be curved
to facilitate femoral head coverage. B, Completed osteotomy
with medial displacement of distal fragment for
interpositional capsular arthroplasty

41.  CHIARI

42. PALLIATIVE OPERATION
 Reserve for cases is which reduction is not possible by
either open or closed reduction as in old unreduced
congenital dislocation.
 Designed to improve :
 Stability.
 Decrease lordosis.
 Control pain arising from lower back/hip.

44. SURGICAL PLANNING
 In surgical planning of an osteotomy, the most
important task is to determine whether the
patient is an appropriate candidate.
Determining factors are the patient’s age,
activities, goals, radiographic assessment,
range of motion, and leg lengths and the status
of the knee of same side.

45. FEMORAL OSTEOTOMY
 Primary objective is deflection of wt. bearing by
angulation of femur to bring the axis of the femoral
shaft more in line with the direction of weight
transmission.
 The osteotomy performed are Angulation
Osteotomy (Stabilizing osteotomy).
 Schanz osteotomy.
 Lorenz osteotomy.

46. SCHANZ OSTEOTOMY (LOW Subtrochanteric
OSTEOTOMY)
(a)Femur is sectioned transversely a lower border of pelvis.
(b)Upper end is angled inward until it rest against side wall of pelvis.

47.  Schanz osteotomy :
 In this osteotomy the deformity flexion, adduction &
external Rotation is corrected by making the osteotomy
at tuber ischii level.
 Preparation :
 X-ray are taken with full adduction – to measure
angle medially.
 Thomas Test - measure degree of flexion to be
corrected.
 Advantages :
 Lurching gait will be diminished.
 The depression of the trochanter also improves the
leverage of the glutei.

48.  Contraindication : Before 15 years of age, because loss
of angulation during growth period.
 Lorenz (Bifurcation osteotomy)
 In this upper end of the lower fragment is abducted and
inserted in to the acetabulum after making on
intertrochanteric osteotomy. “Plane of osteotomy” below
& outward to above & inward.
 Disadvantage :
 Increased shortening.
 Less mobility and arthritic pain.

49. LORENZ (BIFURCATION OSTEOTOMY)
(A) Plane of
osteotomy – Distal
end at posterolateral
aspect towards
proximal end at
anteromedial aspect.
(B) Limb is Abducted
and extended so proximal
end of distal fragment
directed medially and
anteriorly in acetabulum.

50. OSTEOTOMY FOR COXA VARA
 The normal femoral neck shaft angle in infant is 1200 to 1400,
Reduction to a more acute angle constitute a coxa vara
deformity.
 The goal of treatment are
 To promote ossification of the defect and correct varus
deformity.
 Indication for surgery :
 Increasing coxa vara
 Neck shaft angle less than 110°.
 Painful unilateral or associated with leg length
discrepancy
 Hilgenreiner - epiphy seal angle of more than 60° .

51.  Surgery performed are
 Valgus Subtrochanteric Osteotomy or abduction
osteotomy-with Internal Fixation.
 A transverse osteotomy at about the level of lesser
trochanter.
 If necessary take a small lateral wedge to correct neck
shaft angle to 135-150.
 The surgery may be delayed till child is 4 to 5 year old
to make internal fixation easier.

52.  Alternative Method : Pauwels Y shaped osteotomy :
 Static forces are converted from shearing to impacting
forces
 Prerequisites :
 Viable femoral head.
 Young vigorous patient.
 Advantage :
 Union is rapid.
 Recurrence is less likely.

53. PAUWELS Y SHAPED
OSTEOTOMY

54. COXA VERA

55. COXA VARA

56. OSTEOTOMY FOR RELIEF OF PAIN IN
OSTEOARTHRITIS
 Before the onset of osteoarthritis, if normal or near normal
function of the hip can be maintained, reconstructive
osteotomy can prevent or delay the development of
osteoarthritis; if mild or moderate osteoarthritis is present, a
salvage osteotomy can improve function and delay the need
for total hip Arthroplasty.

57. Factors Reconstructive Osteotomy Salvage Osteotomy
Age Generally < 25 years Generally < 50 years (Some
biological Plasticity
Remains)
Symptoms Minimal Moderate to Severe
Motion Near Normal > 600 Flexion
Function Near Normal Fair to Poor
Pathoanatomy No Irreversible Changes Irreversible Changes
Roentgenography Congruent but Malaligned
Surfaces
Cartilage narrowing or
incongruity or both
Prognosis if
untreated
Poor Poor
THERAPEUTIC INTERVENTION IN HIP DIEASE
:RECONSTRUCTIVE VERSES SALVAGE OSTEOTOMY

58.  The goal of reconstructive osteotomies, femoral or pelvic, is to
restore as nearly normal anatomy as possible, thus returning
joint pressures and loading patterns to normal.
 The goal of salvage osteotomies are to relieve pain and
improve function enough to delay the need for total hip
Arthroplasty, especially in active patients younger than 50
years of age.

59. Pre –op planning
 Xrays of hip in maximum adduction and
abduction.
 Tenotomy if necessary
 Determine in which position the head attains
best fit with the acetabulum
 Range of abduction and adduction will
determine the angle of the wedge so that the
limb can attain in the neutral position

61.  varus osteotomy :-
 Designed to elevate the greater trochanter and move it laterally
while moving the abductor and psoas muscles medially, to
restore joint congruity and decrease muscle forces about the
hip.
 Indications- patients with a spherical femoral head, little or no
acetabular dysplasia center-edge angle of at least 15 to 20
degrees),a valgus neck-shaft angle of more than 135
degrees,fixed abduction deformity.
 C/I-fixed ext. rotation >25 deg,flexion of 70 deg
 Varus osteotomy with medial displacement of the femoral
shaft relaxes the abductor, psoas, and adductor muscles
unloads the hip joint, and increases the weight-bearing surface.

66. Varus osteotomy increases weight bearing area of femoral head
while relaxing all three important muscle groups around hip joint

67. Three types of wedges cut for varus osteotomy. A, Original technique of Pauwels with proximal
osteotomy made transversely at distal end of greater trochanter. This type of osteotomy makes
it more difficult to correct rotation and to use right-angled blade plate. B, Original Müller
technique of excision of wide wedge based medially with distal osteotomy cut transversely
across shaft at just above level of lesser trochanter. C, Later technique of Müller using small
half wedge cut medially and transposed laterally.

68. VARUS OSTEOTOMIES

69.  Most authors recommend medial displacement of 10 to
15 mm to keep the ipsilateral knee centered under the
femoral head and to maintain the mechanical axis of the
leg.
 Varus osteotomy, however, shortens the limb to some
degree. creates a Trendelenburg gait that may persist for
months after surgery, and increases the prominence of the
greater trochanter.
 Limb shortening can be minimized by making a smaller
medial osteotomy and transposing it to the lateral side.

75. VALGUS INTERTROCHANTERIC
FEMORAL OSTEOTOMIES
 Valgus Osteotomy - Increase weight bearing area of femur
head.
 It does not produce muscle relaxation.
 Relaxation obtained by tenotomy of Iliopsos and adductor
muscle.
 Transfer the center of hip rotation medially from the superior
aspect of the acetabulum to increase joint congruity and the
weight-bearing area of the femoral head.
 Osteotomy of the greater trochanter often is performed with
valgus femoral osteotomy to move the greater trochanter
laterally.

76.  INDICATIONS : FIXED ADDUCTION
DEFORMITY
 CONTRAINDICATIONS : FLEXION OF
LESS THAN 60 DEGREES, KNOCK KNEES

77.  Best result were obtained in patients younger than 40 years of
age with unilateral involvement, good preoperative range of
motion, and a mechanical (secondary) cause.
 Most surgeons now advise that all osteotomies be fixed with
rigid internal fixation, which offers several obvious
advantages:
 The fragments are maintained in proper position;
 The danger of limitation of motion of the hip and knee is
greatly decreased;

78.  The patient can be allowed out of bed early; and
 Pulmonary, urological, and other medical complications
are decreased. A device frequently used for rigid internal
fixation of intertrochanteric osteotomies is the ASIF, or
right-angled, blade plate.
 Nonunion has been a troublesome complication after
Osteotomy, and an incidence as high as 20% has been
reported.

79. BIOMECHANICAL TREATMENT OF
OSTEOARTHRITIS
 Therapy must be directed at reducing joint loads. This may
be by reducing the compressive forces directly or by
increasing the weight- bearing area, and thereby reducing
the load per unit area or ideally by combination of the two.

80. WHILE PERFORMING OSTEOTOMY
 The distal cut must be perpendicular to the axis of the shaft
fragment.
 All cortical wages are taken form the proximal fragment to
avoid loss of apposition when the distal fragment is rotated.
 General contraindication of femoral osteotomies -
 Poor motion
 Inflamatory joint condition
 Significant metabolic disease.
 Severe degenerative joint disease.

81. OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
 Sarmiento Technique

82. OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
 Dimon and Hughston :
 Described technique of Trochanteric osteotomy with
valgus nailing and medial displacement to improve
stability there techniques are occasionally useful in some
extremely comminuted fractures.
 Recent studies have indicated that anatomical reduction
allow greater load shearing by bone than medial
displacement osteotomy.

83. DIMON AND HUGHSTON METHOD OF
INTERTROCHANTERIC OSTEOTOMY

84. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 Is a disorder in which there is a displacement of the capital
femoral epiphysis form the metaphysis through the physeal
plate.
 By this head is placed in posterior & downward position in
acetabulum.
 The goal of treatment is
 To prevent further displacement and
 To promote closure of physeal plate.

85.  The use of realignment procedure such as lntertrochameric,
Subtrochanteric Osteotomy & osteotomies the around neck is
in those situation in which restricted range of motion impairs
function after plate physeal closure.
 Principle of Osteotomy
 There are basically three type of Deformity present in SCFE.
These are-
 Varus
 Hyper extension
 Moderate Severe external rotation

86. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
 The osteotomy to correct these
deformities work at two sites.
 Through the femoral neck
(closing wedge osteotomy)
 Through the trochanteric
area.

88. EXTRACAPSULAR BASE OF NECK
OSTEOTOMY
 types of femoral neck osteotomy are -
 The technique of Dunn - for severe chronic slip with
open physis.
 Base of the neck osteotomy - Compensatory Basilar most
of femoral neck. (Kramer) - correct the varus and
retroversion component of moderate to severe chronic
SCFE.
 It is safer than cuniform osteotomy of neck.
 Further slipping is prevented.
 Intertrochantric osteotomies

89. CORRECTIVE OSTOTOMIES
 By these osteotomies one can correct angulation, rotation,
flexion, extension Deformity of bones to restore motion for
patient with stiff hip.
 Like
 Deformities in septic arthritis
 Malunion of I/T femurs
 Neuromuscular disorder
 Cerebral palsy
 Poliomyelitis

90.  There are three types of corrective osteotomies
 Close wedge - transverse closing wedge provide good bony
apposition and is stable, however, it shortens the extremity.
 Open wedge - simple and lengthens the extremity however.
bony apposition is limited, union is delayed in adults and it
is initially unstable.
 Ball and Socket type - achieves stability without shortening
the extremity; however, extensive dissection is required,
and in severe biplame deformities an accurate and stable
osteotomy is difficult to perform.
 In Ball & socket type of osteotomy concave surface in created
in the proximal fragment of convex surface at the distal
fragment, at intertrochantaric level & fixed in place by plate.

91. CORRECTIVE OSTOTOMIES
Brackett ball and socket
Osteotomy
Whitman closing wedge
Osteotomy
Gant-opening wedge
Osteotomy

92. FRACTURE NECK FEMUR
 In those case which present late (1-5 wks.), are difficult case
to treat because
 Close reduction is not possible.
 Open reduction is associated AVN
 In young Pt. with viable femoral head & nonunion options
are-
 Mcmurray & Pauwel’s ‘y’ osteotomy
 Angulation Osteotomy (Schanz)
 Dickson geometric osteotomy
 In old Pt.-
 Mcmurray Displacement

93. OBLIQUE OSTEOTOMY
 Extends from lateral aspect of shaft at level just below the
lower border of lesser trochanter and terminates medially
between lesser trochanter and lower border of neck.
 Shaft is displaced medially.
 Mechanical Advantage :-
 Line of weight bearing shifted medially.
 Shearing forces at the nounion is decrease because
fracture surface become more horizontal
 These advantages are greater after angulation osteotomy.

94. McMURRAY

95. MC-MURRAY OSTEOTOMY

96. MC-MURRAY’S OSTEOTOMY
 The oblique osteotomy extends from the lateral aspect of
the shaft at a level just below the lower border of the
lesser trochanter and lower border of neck.Then the limb
is rotated inward and outward to remove any bony spike
 Fixation of osteotomy - By Compression nail
plate./Castle Plate.
 Disadvantages:
 Instability - Degenerative changes in normal head
 Shortening - AVN when neck have been fractured
 Medial displacement of shaft compromise the
insertion of femoral stem of total hip.
 Advantage -Changes line of fracture to
horizontal,callus may incarporate fracture

97. DICKSON HIGH GEOMETRIC
OSTEOTOMY
 Principle - the line of vertical force
is converted to a horizontal
(impacting force). In this distal
fragment is abducted to 60° after
making osteotomy just below the
grater trochanter & fixed with plate.
 High rate of union
 Lengthens limb
 Improves abductor strength

98.  OSTEOTOMIES –
 These procedure have achieved best result for small and
medium sized lesion. 1<30% femoral head involvement in
young pt.
 Intertrochanteric varus/valgus - osteotomies
 Transtrochantric ant. Rotational osteotomy (Sugioka) -
Technically Demanding procedures.
 PRINCIPLE:
 All osteotomies are designed to transfer the weight
bearing forces form the necrotic area to the cartilage on
the sound part of the femoral head to allow healing of
necrotic area by hyper vascularisation of upper part of
femur.
AVN

99. TRANSTROCHANTRIC ANT. ROTATIONAL
OSTEOTOMY [SUGIOKA]

100. TECHNIQUE FOR ROTATION
 Femoral head is rotated anteriorly (450 - 900) by handling
proximal pin.

101. OSTEOTOMY IN PERTHE'S DISEASE
 Salvage :
 Varus Derotational Osteotomy
 Innominate Osteotomy.
 MRI / Arthrogram before surgery is mandatory.
 Varus/derotation osteotomy of this embodies the principle
of “containment” of the diseased femoral head in the
treatment of Legg - Calve-Perthes disease.
 Guide pin inserted compression screw is placed over
guide wire.

102.  Appropriate angled osteotomy is made.
 Wedge is removed.
 Make osteotomy as proximal as possible just below lag
screw for -
 Better Healing
 Better correction of deformity.
 Reduce the osteotomy and fixed with plate and
compression screw.

103. SUBTROCHANTERIC DEROTATION
AND VARUS OSTEOTOMY
 The aim of surgery is to center the whole "plastic" epiphysis
inside the joint cavity, keeping it well covered by the roof of
the acetabulum and allowing the child to walk so that the
redistributed intra-articular pressures will contribute the
molding of a more normal joint.
 A small 4-hole plate is bent to the desired angle, and a
subtrochanteric osteotomy is done followed by derotation and
yarns angulation of the shaft. A double hip spica is applied
and the removed 2 months later. When the osteotomy site is
united, the child is encouraged to walk, then with walking aids
and finally without support.

104. VARUS DEROTATION OSTEOTOMY

105.  The operation is best suited for early stage of Leg-Calve-
Perthes’ disease, preferably those under the age of 7 years.
 Axer : Described lateral open wedge osteotomy for children
< 5 years with perthes disease. Defect laterally fills rapidly
in young children > 5 years of age delayed or non union may
occur.

106. RECONSTRUCTIVE SURGERY
 Valgus subtrochanteric osteotomy – for Hinged
Abduction
 Shelf Augmentation – Coxa Magna.
 Chilectomy - Malformed head in late III Group.
 Chiari's Pelvic Osteotomy - Large Malformed
Femoral Head with Subluxation laterally.

107. THANK YOU